Case reports are defined as the scientific documentation of a single clinical observation and have a time-honored and rich tradition in medicine and scientific publication. This article discusses the role and relevance of case reports in the current evidence-based medical literature. It also seeks to help and guide authors to understand how to prepare a reasonable and well-written case report and how they may anticipate concerns that peer reviewers may express when scrutinizing their manuscript. An overview of the Journal of Conservative Dentistry's review process of a manuscript submission is provided for the benefit of future authors. It is important to be able to read a case report critically and to use the information they contain appropriately. This article also discusses the factors to consider in evaluating individual case reports, and discusses a practical conceptual scheme for evaluating the potential value and educational content of a case report.

Keywords: Case report; dental writing; publishing

How to cite this article:Gopikrishna V. A report on case reports. J Conserv Dent 2010;13:265-71

Always note and record the unusual…Publish it. Place it on permanent record as a short, concise note. Such communications are always of value.

- Sir William Osler

The clinical case report, which describes and analyzes the diagnosis and/or the management of one or two patients, is the first line of evidence in health care. [1],[2],[3] A case report is a powerful tool to disseminate information on unusual clinical syndromes, disease associations, unusual side effects to therapy, or response to treatment. Case reports have been used for years as a means to teach health sciences students, [2],[4] and are one of the best ways for authors to get started in scholarly writing, [2],[5],[6] and can be a valuable learning experience for both author and reader. Case reports continue to be a very popular section within the Journal. They are well read, and by nature they are easily accessible. [6]

Among the many reasons that explain the popularity of case reports, the main one is probably the accessible nature of this particular piece of clinical information. Symbol of the high popularity in the Journal is the continuous rise in the number of case report submissions [Figure 1]. The Journal has always witnessed a steady stream of case reports, but over the last years the number has increased significantly. This year we received 86 case reports, and this represented a tenfold increase in comparison with 2008.

Figure 1: The number of manuscripts that are submitted as a case report to the Journal of Conservative Dentistry in comparison with the number of manuscripts that were accepted for publication and those that were rejected for the period 2008-2010.

The Journal of Conservative Dentistry receives more case reports than it can publish. Unfortunately, although many of these manuscripts are academically worthy, they are too poorly written to merit acceptance. Some manuscripts are considered beyond salvage, and these are rejected outright. Other manuscripts pass through one or more rounds of peer review before an editorial decision is taken. In both these situations, and especially in the latter, the editorial office and the reviewers of the manuscripts are taxed, this wastes time and resources, and the waste is a complete loss for all involved if the manuscript is eventually rejected.

This article seeks to help and guide authors to understand how to prepare a reasonable and well-written case report. Writing a good research paper is an art that requires skills in both academic and literary domains. Articles that are better in quality at the time of original submission will stand a higher chance of acceptance.

This article hopes to help authors to better understand the nuances involved in the preparation of a case report and how they may anticipate concerns that peer reviewers may express when scrutinizing their manuscript. The objectives of this article are to improve the chances that authors will receive a favorable review for their own manuscripts, and to thereby reduce the burden that the reviewers and editorial office of the Journal of Conservative Dentistry experience with submissions that require extensive and repeated rounds of revision.

The Relevance of Case Reports in Contemporary Journals

Case reports constitute a small segment of the medical literature; about 7% of the articles published in general medical and family practice journals, according to one study. [7] The single case report occupies a pretty low rung on the ladder of evidence-based medicine, which today's students, investigators, and clinicians are admonished to climb diligently in their quest for scientific truth and rational clinical decision making. Available schemes for ranking the various levels of evidence place randomized controlled trials at the top - superseded only by meta-analyses of multiple randomized controlled trials and retrospective studies, case series, and unsystematic observations at the bottom. [8] Most such hierarchies do not list case reports at all. Those that do, relegate them to the evidence ladder's lowest rungs along with the anecdotal observation and expert opinion. Data from a single case, and any conclusions or speculation drawn from it, clearly do not have the weight of findings of the other types of research studies such as clinical trials, [9] retrospective studies, [10] and surveys. [11]

On the other hand, several authors have pointed out that, prepared carefully and interpreted with appropriate circumspection, case reports have a valuable part to play in both the advance of medical knowledge and the pursuit of education. [12],[13],[14],[15]

A well-documented account of something not previously reported in the literature can be a useful contribution. In his monograph on writing and publishing in the health sciences, Huth [16] lists four types of cases that may constitute worthwhile contributions to the medical literature:

A unique case that may represent a previously unknown syndrome or disease.

A case with the previously unreported association of two distinct diseases, suggesting a possible relationship between them.

An "outlier" with features strikingly outside the realm of what is usually seen with a particular disease.

An unexpected response or course suggesting a previously unrecognized therapeutic or adverse effect of intervention.

Added to this list for readers and potential authors of Journal of Conservative Dentistry, with examples that our Journal has published in recent issues, might be:

Demonstration in a patient of a phenomenon or response to an intervention using a newer material or technique that was previously demonstrated only in animal models, e.g.: pulpal response to a newer pulp capping agent. [17]

Documentation of a new manifestation or finding, or clearer demonstration of a known feature of a disease, using a new technology or method, e.g.: using computed tomography for diagnosis of an unusual feature of a disease. [18]

Documentation with clinical follow-up of a newer treatment method or intervention for a disease process, e.g.: a newer method of surgical decompression of an infected radicular cyst. [19]

Demonstration of a previously unreported unique variation in root canal anatomical configuration, e.g.: a case report on the unusual location of second mesiobuccal canal orifice. [20]

Demonstration of the efficacy of a newer technique of intervention with a sufficient period of follow-up to support, e.g.: using a newer material for furcal perforation repair with a sufficient clinical follow-up. [21]

A previously unreported finding in a rare condition that suggests a possible pathogenetic mechanism.

A new manifestation or finding, or clearer demonstration of a known feature of a disease, using a new technology or method.

Demonstration, by means of modern technology, of known physiologic principles through the findings in a patient with a rare condition.

A clinically important hazard or potential problem associated with the use of a diagnostic or therapeutic device or material.

What does an Editorial Office Look for in a Submission?

Content of case reports

Sorinola et al.[22] surveyed the current advice available to authors of case reports from "instructions to authors" pages of a core collection of 249 journals ("Hague" list). These were examined and compared for advice or recommendation on writing case reports. The majority of information provided on the kind of case reports the journal publishes were on:

whether the case has to be unusual or not was required by 99 (60%) of the surveyed journals,

whether an instructive or teaching point was conveyed in the case report was required by 91 (55%) journals,

whether the case is an original and innovative one was required by 42 (26%) journals, and

Only 9 (6%) journals considered the hypothesis generation a reason for reporting the case.

Instructions for authors

Journal editors differ in what they look for in a submission, but a review of the instructions to authors in 163 medical journals revealed a median limit of 1000 words, eight references, and six authors for case reports. [22] Approximately, 90% of the journals requested an abstract and key words. In this era of electronic databases, it is essential that you provide this information if you want your report to be accessible to the reader. Sixty-one percent were looking for the unusual or rare content, while 55% requested that the content should be instructive. In your cover letter to the editor, make sure that you sell your manuscript by articulating the salient educational message. Brevity and clarity are essential assets if a submission is to meet the journal's space requirements and retain the reader's interest.

Manuscript review process

What happens with the case report once you submit it? First, the Editorial Office checks whether the manuscript meets the technical standards and that it is complete. If so, your manuscript moves to the next stage, and that is the editorial board meeting. Here we discuss your paper and judge whether it meets the standard of the Journal. This is a major hurdle, and we have to admit that not many manuscripts get beyond this stage. Next, we send your paper out for review, and after a receipt of the referee reports, one of the editorial board members issues a recommendation. The Editorial Board discusses the paper again, in view of the recommendation. If we agree that the case report is potentially interesting, we ask you to write a rebuttal and change the manuscript according to the issues raised by the reviewer. Now we have come to the final stage and here the editorial board member checks whether the referee's issues have been dealt with. If there is any doubt at this stage, the paper can be rejected or we get back to you with additional questions. Finally, if you manage to get beyond this stage, your paper is accepted in the Journal and you can await publication.

Why do many case reports not get that far? As you may have noticed, we only publish two to three case reports each issue and with four Journal issues, it becomes clear that we cannot print all submissions. Indeed, we rejected 75 of the 86 case report submissions this year [Figure 1]. How do we decide what to take or not to take? We, the Editorial Board, are committed to the Journal, and we need to apply strict quality control measures in order to maintain the high standard of the journal. [23]

How to Report a Case

The following section would deal on the essential basic nuances in the compilation of a case report. Case reports should be short and focused, with a limited number of figures and references. There are usually a restricted number of authors. The structure of a case report usually comprises a short unstructured (or no) abstract, brief (or no) introduction, report of the case, and discussion [Table 1]. Unlike original articles, case reports do not follow the standard IMRAD structure of the manuscript organization. As there is a wide variation in the format for case reports among different journals, it is essential for authors to follow exactly the target journal's Instructions to Authors.

The title should accurately and succinctly describe the case, and be sufficiently informative to interest the reader. Redundant words such as "case report" or "review of the literature" should be omitted. Clever or artistic titles should not be used because it is confusing and makes it difficult for the reader to determine the focus of the paper.

Authorship

Determining who will be listed as authors on a paper, and in what order, is an important process. It is convention that the author who does the most work on the project is listed first and only those involved in a substantive way are listed as authors. Past abuses in the authorship have created a need for clear authorship criteria, which have been provided by the International Committee of Medical Journal Editors (ICMJE). [24] Since it is unlikely that a single case will be managed by a large team of providers, one would not expect to see more than a few authors on a case report. One paper titled "Does it take a village to write a Case Report?" [25] demonstrates that some have successfully used the case report as a means to enhance their curriculum vitae. One study has objectively demonstrated that case reports contain too many authors. [26]

According to the International Committee of Medical Journal Editors guidelines, one may only be considered an author only if he or she meets all of the following three criteria:

He/she has provided substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data.

He/she has drafted the article or revised it critically for important intellectual contents.

He/she has given the final approval of the version to be published. [24]

Anyone who does not meet all the three criteria, but who has contributed to the paper, may be thanked for their contribution in the acknowledgements section of the manuscript. [25],[26]

Abstract

For some journals, no abstract is needed for case reports. If required, the abstract should be unstructured, and provide enough essential information for other researchers doing a database search. Abstracts for case reports are generally shorter than for other categories of papers, and are typically 100 words or less in length.

Key words

Use terms found in the Index Medicus database, which are called medical subheadings (MeSH). MeSH can be found at the PubMed home page (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=mesh). A list of additional words that may be unique to the case or to the topic are also discussed.

Introduction

The introduction section must state clearly why the case report is worth publishing and reading, not only because a statement of rationale is intrinsically logical but also because busy clinicians are unwilling to read an article if they cannot anticipate its interest or relevance to them and their practice.

The acceptable case report makes a contribution by illustrating a useful new approach to the diagnosis or the management of a condition or by offering a new insight into the pathogenesis of a disease. The introduction section should also contain some evidence from the literature to substantiate the authors claim that the case is important.

Case report

In writing a case report, the order of events should be presented in chronological order, typically comprising clinical history, physical examination findings, investigative results, differential diagnosis, working diagnosis, management, follow-up, and final diagnosis. Clarity is essential, especially with regard to important findings, all of which should be reported honestly. The presenting signs and symptoms should be objectively described, together with the relevant past dental history.

Patient confidentiality

Authors of case reports must be cognizant of the need to protect patient confidentiality, and specifically to safeguard protected health information, as defined by the Health Information Portability and Accountability Act (HIPAA). [27],[28] The latter is defined by HIPAA as "any information that is entered, created, or received by health care providers that relates to the past, present, or future physical or mental health of any individual or to the provision of health care to that individual and that identifies the individual." [28]

Preserving patient confidentiality is paramount. It is important that the patient is not identifiable from the information contained in the text of the case report. In the accompanying images, authors should make every effort to remove or conceal all identifiable features, taking particular care with the head and face. The eyes should be blanked out, and any birthmarks or tattoos concealed. It is preferable to obtain a written informed consent from the patient or parent/guardian (if the patient is a minor) giving permission to publish the case report and accompanying images.

Discussion

The discussion section serves to explain, clarify, and interpret key findings, and should be brief and to-the-point. An overview of the typical management may be required. The authors may suggest or explain their hypothesis, and express their own opinion here. A commentary that puts the case in context of other similar cases or explains specific management decisions is useful. Any shortfalls or limitations of the case should be stated. The value that the case adds to the current literature should be highlighted, so should differences between the reported case and other similar cases. Authors should also try to indicate the direction for future investigation, or the diagnosis or management of similar cases. In the last paragraph, the main conclusions of the case report, and an explanation of its importance or relevance should be provided. The take-home points should be emphasized, with focus on the main learning points, which should relate to the purpose for reporting the case.

A case report check list [Table 2] is being provided for future authors to use as a form of self-evaluation prior to submitting a manuscript to a journal to determine if further work is necessary before submission.

Whether it documents new scientific knowledge or provides an educational resource on a previously known entity, the potential validity and value of a case report are determined by the following characteristics:

How well the case is documented

Its uniqueness and/or educational value

The objectivity with which it is described

How the information is interpreted with respect to broader principles and applicability to other patients

Pierson [29] has formulated a conceptual scheme with component domains for evaluating the quality of a case report [Figure 2] and [Table 3].

Figure 2: Piersons conceptual scheme for evaluating the quality of a case report

The value of individual case reports should be kept in perspective in the larger context of the scientific literature. Appropriately viewed, however, the case report remains an important cog in the wheel of medical progress, which can stimulate clinicians' interest, generate further research, or serve as a helpful educational tool. The application of the principles summarized in this article can help a potential author to prepare a case report in a more acceptable format and would help the reader to approach case reports critically and gain maximum benefit from them.

Summary

A case report will not have as much potential impact on the science or practice of health care as a randomized controlled trial or other research projects. However, it may be the only way to make others in the field aware of unusual presentations or complications, and it is a time-honored vehicle for teaching others. New syndromes, manifestations, associations, complications, or outcomes are appropriate subjects for case reports, as are typical and exceptionally well-documented examples of known entities that are relevant to a journal's readers.